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Published on: November 28, 2018
Safety of expedited anticoagulation in patients undergoing transesophageal echocardiographic-guided cardioversion
Lambert A Wu1, Krishnaswamy Chandrasekaran, Paul A Friedman
1Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn 55905, USA.
Insights
An expedited heparin anticoagulation regimen is safe for transesophageal echocardiography-guided cardioversion in atrial fibrillation patients. This approach allows earlier cardioversion and safe bridging with low-molecular-weight heparin.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Transesophageal echocardiography-guided cardioversion is a common procedure for atrial fibrillation.
- Standard anticoagulation protocols can prolong hospitalization.
- An expedited regimen using shorter unfractionated heparin and low-molecular-weight heparin bridging was evaluated.
Purpose of the Study:
- To assess the safety and efficacy of an expedited in-hospital anticoagulation regimen.
- To evaluate shorter durations of intravenous unfractionated heparin (UFH) before cardioversion.
- To examine postcardioversion bridging therapy with low-molecular-weight heparin (LMWH).
Main Methods:
- Adult patients with atrial fibrillation/flutter undergoing cardioversion were studied.
- Patients were grouped by UFH duration (<24h vs. >=24h) before cardioversion.
- Safety endpoints included death, stroke, thromboembolism, and major bleeding within 1 month.
Main Results:
- 386 patients were analyzed; 199 received expedited UFH (<24h).
- Adverse event rates were similar between UFH groups.
- Stroke rate was <1% in patients on LMWH bridging; no adverse events in UFH <12h + LMWH group.
Conclusions:
- Expedited heparin anticoagulation is safe for TEE-guided cardioversion.
- Cardioversion can be performed hours after UFH initiation.
- LMWH bridging is effective until therapeutic INR is achieved.
Background:
In patients undergoing transesophageal echocardiography-guided cardioversion, we evaluated the use and safety of an expedited in-hospital anticoagulation regimen that incorporates shorter-than-standard durations of precardioversion intravenous unfractionated heparin and postcardioversion bridging therapy with a low-molecular-weight heparin.
Methods:
Adult patients who underwent successful transesophageal echocardiography-guided cardioversion for atrial fibrillation or atrial flutter between May 2000 and August 2003 were classified into 2 groups by duration of intravenous unfractionated heparin therapy (<24 h or > or =24 h) before transesophageal echocardiography and cardioversion. Safety end points evaluated included all-cause death, stroke or other thromboembolic events, and major bleeding complications within 1 month after successful cardioversion.
Results:
The study population of 386 patients included 199 (52%) who received expedited intravenous unfractionated heparin (<24 h; minimum duration, <4 h) and 193 patients (50%) who were discharged on low-molecular-weight heparin therapy. The adverse event rates at 1-month follow-up were not significantly different between the 2 unfractionated heparin patient groups, and the rate of stroke among patients dismissed on low-molecular-weight heparin was less than 1%. No adverse events occurred among patients who received intravenous unfractionated heparin for less than 12 hours and who were dismissed on low-molecular-weight heparin bridging therapy.
Conclusions:
The use of an expedited heparin anticoagulation regimen in patients with atrial fibrillation or atrial flutter undergoing transesophageal echocardiography-guided cardioversion appears to be safe. Cardioversion can be performed as early as a few hours after initiation of intravenous unfractionated heparin, and bridging therapy with a low-molecular-weight heparin can be used after cardioversion until the international normalized ratio is therapeutic.
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